Health Insurance Costs

How much is the premium?

$_____________________________________________

Are there any discounts available for good health or healthy behaviors (e.g., non-smoker)?

__________________________________________________________________

How much is the annual deductible?

$_________________________________ per person

$_________________________________ per family

What coinsurance or co-payments apply?

_________________________________% after I meet my deductible

$_________________________________copay or % coinsurance per office visit

$_________________________________copay or % coinsurance for "wellness" care (includes well-baby care, annual eye exam, physical, etc.)

$_________________________________% copay or coinsurance for inpatient hospital care